Initial vitals:
R: 40, O2: 85%, P: 160, BP: 90/60, T: 37.6
On exam, The patient is sitting upright, airway is patent but patient is tachypneic, with intercostal retractions and tracheal tugging. You hear wheezing in all lung fields. No stridor.
Which describes best initial course of treatment?
Humidified oxygen, IVF’s and preparation for tracheostomy
Racemic epinephrine and preparation for intubation
Nebulized albuterol and ipratropium bromide, IV steroids, subcutaneous epinephrine and prepare to intubate
IVF’s and supplemental oxygen
The patient is in severe respiratory distress. The patient has a pulse and a patent airway. The history and physical exam findings are most suggestive of severe asthma exacerbation. The initial treatment for asthma exacerbations include nebulizers, IV steroids, magnesium, and possibly epinephrine, based on the severity of the exacerbation. In this instance, it is appropriate to initiate these treatments, attempting to stave off intubation, but preparing for intubation simultaneously. IVF’s may be helpful but are not the mainstay of treatment. Racemic epinephrine is indicated for croup or other upper airway obstruction but not in asthma as this is lower airway pathology. A tracheostomy would be indicated if patient is in respiratory distress due to an upper airway blockage but not as initial invasive ventilation in asthma exacerbation.
The monitor demonstrates the following
What is your first step in management?
Initiate CPR
Check a pulse
Defibrillate
Synchronized cardioversion
For any change in patient’s clinical scenario, one must constantly reassess the patient. If the patient has a pulse, this is considered sinus tachycardia on the monitor. If the patient does not have a pulse, this would be indicative of pulseless electrical activity (PEA) and would require initiation of CPR and appropriate related PALS care.
Subsequent to intubation, the blood pressure is markedly decreased and on reevaluation, the patient has become pulseless, although telemetry monitor remains unchanged.
What is your next step in management?
Administer amiodarone
Initiate CPR and give epinephrine
The patient is still demonstrating sinus tachycardia on the monitor, but is pulseless, which represents PEA (pulseless electrical activity). This rhythm is not amenable to treatment with cardioversion or defibrillation. Rather, administer effective CPR, and give epinephrine for management, while treating and addressing the underlying cause (in this case as in most pediatric cases, likely respiratory arrest/hypoxia).
What is the appropriate concentration and dose of epinephrine to be administered?
0.01 mg/kg of 1:10,000 IV every 3-5 minutes
0.02 mg/kg of 1: 1,000 IV every 2-5 minutes
0.1 mg/kg of 1: 10,000 IV every 3-5 minutes
0.01 mg/kg of 1: 1,000 IV every 3-5 minutes
Epinephrine administered in a code situation/pulseless patient is ideally administered via IV or IO. The concentration is 1:10,000 IV.
